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Effect of positioning of artificial teeth, contouring and body forms

following rehabilitation of resorbed mandibular ridges: Case reports

Article  in  International Journal of Oral Health Dentistry · October 2019

DOI: 10.18231/j.ijohd.2019.036

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Case Report http://doi.org/10.18231/j.ijohd.2019.036

Effect of positioning of artificial teeth, contouring and body forms following rehabilitation
of resorbed mandibular ridges: Case reports
Varun Kumar1*, Rahul Dhami2, Avneet Kaur3, Vibhuti Aeran4
1Professor, 2Reader, 3Post Graduate Student, 4Final Year Student, Dept. of Prosthodontics, Seema Dental College & Hospital, Rishikesh,
Uttarakhand, India

*Corresponding Author: Varun Kumar

Email: drvarun_smile@yahoo.co.in

Abstract
The successful rehabilitation of completely edentulous patient is a pleasant surprise for old aged patient and a reward to a prosthodontist.
Although implant supported prosthesis have grown as a new treatment trend for edentulous patients but choosing the best form of therapy
should reflect dentist’s knowledge for effectiveness of treatment and at the same time patient understanding of treatment risks and also cost
effectiveness. In developing countries, cost is being a major determinant of patient’s choice specially with unemployed residual ridge. In this
case report a clinical technique has been explained for physiologic registration of denture tooth position, denture base contours and body
forms for resorbed mandibular ridges.

Keywords: Resorbed ridge, Neutral zone, Teeth arrangement, Complete denture.

Introduction impression surface; proper management of occlusion; and

Constructing complete dentures for “difficult lower jaw” as
suggested by Brill1 presents a challenge to the dentists.
Various structures of the oral cavity changes considerably
when a patient becomes edentulous. Because of these
changes the lips and cheeks are no longer supported by the
teeth and bone, and therefore tend to “fall” into the oral cavity
& simultaneously the tongue expands into the space formerly
occupied by the teeth which is partly due to a growth of the
tongue, and has been named proptosis lingualis.2 In this way,
characteristic spaces develop in the oral cavity of edentulous
patient forming the so called denture space. The dynamics of
the tissues surrounding this space determine the form of the
denture.1
Resorption of bone causes the residual crest of the
residual ridge to approach the musculature of the denture
space. Frequently, this development terminates with the
attachment of the mentalis and mylohyoid muscles located
only 2 or 3 mm from the crest of the mandibular residual
ridge.3 Therefore, these muscles can easily dislodge a
denture. Moreover, bone resorption also causes soreness on
the surface of soft tissue that is firmly attached to the
underlying bone to be reduced 4 thus eliminating well-defined
vestibular and lingual sulci. All these events further
complicate the construction of denture.
Thus before constructing a denture, one should be
familiar about following detail: The surface of a denture can
be divided into different regions, each with its own function.
These are: the pressure receiving surface (the occlusal table);
the pressure transmitting surface (the primary supporting
surface or basal seat) and finally; the secondary supporting
surface which is comprised of the polished surfaces of the
denture and the lingual and buccal surfaces of the teeth. The
junction of the primary supporting surface and the secondary
supporting surfaces is called the denture border.
Fish5 published a classic monograph in which he
explained about three principal factors of mandibular
stability as faithful reproduction of maximally available
International Journal of Oral Health Dentistry, July-September, 2019;5(3):157-162
modelling of the polished surfaces to function in harmony
with the orofacial musculature. The importance of properly
shaped external surfaces is best expressed by Fish, “If there
is not much ridge, the impression and occlusal surfaces
cannot resist lateral displacement. Therefore, the only hope
lies in the third or polished surface. It must be fashioned to fit
the lips, cheeks, and tongue, both at rest and in function.”
A detailed protocol of recommended procedures and
materials for accomplishing the neutral zone procedure
should be followed in patients suffering from severe residual
ridge atrophy and/or chronically reduced occlusal vertical
dimension, the procedures discussed here may be used during
most edentulous therapies, including those incorporating
dental implants.
Case Report
Case 1
A sixty five years old female patient reported to the
Department of Prosthodontics, Seema Dental College and
Hospital with her broken lower denture and loosen upper
denture and wanted replacement for the same. Patient gave a
history of loss of teeth over a period of 3-5 years and was
wearing denture since then. On clinical examination, patient
Perioral soft tissue was slack and vertical dimension was also
reduced. On intraoral examination, resorbed maxillary and
mandibular ridges were seen. Maxillary arch showed deep
anterior undercut in the labial vestibular region with small
maxillary tuberosities. (Fig. 1) Mandibular ridge showed
Atwood order-V type of ridge and broad and flattened tongue
along with reduced buccal and lingual vestibular depth.
The planned treatment was immediate replacement for
both upper and lower edentulous arches. Preliminary
impressions for upper and lower arch were made using
impression compound via admix technique (seven parts by
weight of tracing compound and three parts by weight of
impression compound) in nonperforated stock trays for better
recording of available impression surface and poured in
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Varun Kumar et al. Effect of positioning of artificial teeth, contouring and body forms….

TYPE II Gypsum product, i.e. Dental plaster. On these During teeth arrangement first maxillary and mandibular
primary cast special tray were fabricated using self cure anterior teeth were arranged according to the lower rim and
acrylic resin. Border moulding was done using low fusing then mandibular posterior teeth were arranged following
tracing compound and final impressions were made using maxillary posteriors. In order to preserve the contours
zinc oxide eugenol paste (DPI Impression paste) for both established no additional wax was added to the denture
upper and lower arches. Master casts were poured in TYPE flanges. On the next appointment wax try-in was performed
III Gypsum product, Dental Stone. Finally trial denture bases to evaluate the stability, aesthetics, intraoral occlusion and
were fabricated using self cure acrylic resin for both upper phonetics of the patient (Fig. 4). Patient performed all the
and lower arch; and on these occlusal rims were fabricated movements mentioned earlier. Then these trial denture bases
using modelling wax and tentative jaw relation was recorded. were processed with heat-cure acrylic resin. Dentures were
This tentative record was mounted and then lower rim was polished and insertion was done again verifying the
removed. On a new denture base occlusal rim was fabricated occlusion, phonetics and aesthetics of the patient (Fig. 5).
with impression plastic to record neutral zone. In a hot water Patient was recalled periodically to verify comfort and
bath (1400F) seven parts of green stick (DPI pinnacle tracing function.
sticks) and three parts of impression compound (Y-DENT)
by weight were taken and material was kneaded thoroughly
and adapted on record base forming a recording rim. Edges
were sealed using heated wax knife. These completed record
base along with rim were kept in water bath for around two
minutes.
For recording neutral zone the base and rim from the
water bath was removed and quickly placed intraorally. The
patient was instructed to swallow. Next, a cup of warm water
was provided to the patient and was instructed to sip and
swallow. Have the patient repeat this sip and swallow
exercise several times. Then the patient was trained to
perform various exercises like pressing his lips, swallowing,
sucking, moving her tongue in oral cavity touching her palate, Fig. 1: Intaoral view of resorbed mandibular arch
lips and cheeks and take sips of hot water and repeat all these
exercises while keeping her mouth closed. In this way this
coordinated muscle activity plastically shapes the rim to form
the neutral zone. Observe the resulting volume of the neutral
zone record as it defines the area in which the denture teeth
will be placed and all muscle activity recorded on the rim
made of impression plastic (Fig. 2).
When the neutral zone record has cooled and hardened,
remove and inspect the record for accuracy and
completeness. If necessary, we can repeat the procedure to
ensure proper recording of the entire neutral zone. Eliminate
excess modeling plastic impression compound displaced
superior to the intended occlusal plane during the recording
procedure and, if necessary, repeat the recording process, Fig. 2: Neutral zone recorded using admix technique
beginning with the warm water bath.
To develop neutral zone index, (Fig. 3) three notches
were made on the mandibular cast, articulated in a mean
value articulator; one in the anterior and two in the posterior
regions. This was followed by applying separating medium
on the cast, the record base, and over the neutral zone record.
Boxing was done with modelling wax, and plaster of paris
was poured to the upper surface. The plaster indices were
sectioned into a labial and buccal index and lingual index in
order to guide the removal and placement of these indices.
Neutral zone record is then removed; separating medium is
applied on the inner surfaces of indices which were then
reassembled. Wax was heated and poured in the space
representing the neutral zone, forming the new occlusal rim
on the mandibular record base.
Fig. 3: Neutral zone index made using dental plaster

International Journal of Oral Health Dentistry, July-September, 2019;5(3):157-162 158

Varun Kumar et al. Effect of positioning of artificial teeth, contouring and body forms….

by training the patient to perform all tongue and cheek

movements (Fig. 7).
Neutral zone index was made using silicon putty material
around the recorded impression of denture space. Indexing
was made on side and centre of the land area of cast (Fig. 8).
Putty was adapted into the tongue space of the neutral zone
record so that it is in level of occlusal plane of record and
extends over the posterior land area of cast. Likewise facial
matrices were developed along the facial contours of the
neutral zone record. Once polymerized, putty matrices were
sectioned and removed from the cast. Impression compound
is removed from base and replaced with wax using putty
matrices.
Fig. 4: Finished and polished dentures Using the matrices anterior teeth arrangement for upper
and lower arch followed by placement of mandibular
posteriors and then maxillary posteriors were arranged.
Waxed up denture trial (Fig. 9) was done and then dentures
were processed and insertion (Fig. 10) was done. Patient was
asked to perform all the movements explained earlier and was
recalled periodically to check for retention and stability of
dentures.

Fig. 5: Denture insertion

Case 2
A 45 years old male patient reported to the Department of
Prosthodontics, Seema Dental College and Hospital with
chief complaint of difficulty in chewing and replacement of Fig. 6: Impression recorded using closed mouth technique
his old dentures which were loose. Patient was a old denture
wearer, and his old maxillary denture comprised of suction
disc. On examination patient showed resorbed maxillary and
mandibular ridges and slight inflammation with palate.
Patient was advised to stop using his old dentures so that
inflammation can subside and was recalled after a week for
new denture fabrication.
Primary impressions were made using impression
compound and diagnostic cast were poured. Special tray was
fabricated for upper arch and border moulding was performed
using tracing compound and final impression was made. For
lower arch special tray was fabricated along with two
stoppers in molar region and impression was made using
closed mouth technique using admix technique (Fig. 6) and
patient was asked to perform all tongue and cheek
movements as mentioned earlier. Again this impression was Fig. 7: Recorded neutral zone in impression compound
poured primary cast was obtained, on which a new special
tray was fabricated and final impression was made. These
impressions were poured in dental stone to obtain master
casts.
Denture base were fabricated using self cure acrylic resin
along with occlusal rims to record tentative jaw relation of
the patient. Tentative record was mounted and a new rim
using impression compound was made to record neutral zone
International Journal of Oral Health Dentistry, July-September, 2019;5(3):157-162 159
Varun Kumar et al. Effect of positioning of artificial teeth, contouring and body forms….
Fig. 8: Neutral zone indexing done using putty
Fig. 9: Try-in of waxed up denture bases in patient’s mouth
Fig. 10: Denture insertion
Discussion
With the neutral-zone concept, the impression surface is
called the “base” and the polished surface is called the “body”
of the denture. In the past, we did not orient our thinking in
this direction, and as a result, we were less aware of the
problems and their solutions.
In neutral-zone procedure, the external contours are
moulded by muscle function. The mouldable material used to
locate the neutral zone also determines the shape of the arch
and the angles and contours of the body of the denture. These
three entities are determined by the size and function of the
International Journal of Oral Health Dentistry, July-September, 2019;5(3):157-162
tongue and action and tonus of the lips and cheeks. Just as a
primary impression is the first step in developing the
impression surface of the denture, the compound rims which
located the neutral zone can be considered the primary
impression or the first procedure in developing the polished
surface of the denture. The neutral-zone approach advocates
the use of a closed-mouth impression technique.
Wright et al6 demonstrated that in a large number of
patients, the occlusal plane had a constant positional
relationship to specific anatomic landmarks of one half to two
thirds of the way up the retro molar pads and the corners of
the mouth. The pads are relatively stable landmarks even with
advanced ridge resorption. One plausible explanation of this
phenomenon lies in the pressure/tension concept; that is,
pressure causes bone resorption while tension in the region of
muscle attachment preserves bone or even encourages the
deposition of new bone.7
Regardless of the fabrication technique used,
functionally inappropriate denture teeth arrangement or
physiologically unacceptable denture base volume or contour
have been implicated in poor prosthesis stability and
retention, compromised phonetics, inadequate facial tissue
support, inefficient tongue posture and function, and
hyperactive gagging.
Arch arrangement is defined as the buccolingual position
of the teeth with respect to the stress-bearing region or
residual ridge in the horizontal plane. This consideration,
combined with the proper shaping of the external surfaces, is
the heart of the neutral zone philosophy.11 Directives
provided for optimal facial-lingual arrangement of posterior
denture teeth have varied dramatically over the profession’s
long history of complete denture therapy.
Positioning artificial teeth in the neutral zone achieves
two objectives. First, the teeth will not interfere with the
normal muscle function. Second, the forces exerted by the
musculature against the dentures are more favourable for
stability and retention.
Boucher also concluded that when teeth are placed in the
neutral zone, a lack of favourable leverage is compensated
for by the controlling action of the orofacial muscles that
confine the dentures.13
When the anterior teeth are positioned in harmony with
muscle function, the lips will invariably have the proper
aesthetic appearance. As a general rule, the orofacial muscles
must have room to move, or they will move the denture. The
concept of “available denture space” could lead to a
philosophy of muscle avoidance wherein the prosthesis
occupies as little space as possible. This is inadequate,
because the goal is to enlist the neuromuscular system in the
functional stabilization of the lower denture.11
Techniques described here are intended to emphasize
and illustrate the clinical value of recording the physiologic
dynamics of oral and perioral muscle function and of using
this information to develop complete denture contours and
denture tooth positions.
We all have had the experience of inserting a lower
denture which moves upward as soon as the patient opens his
mouth or starts to speak. The first assumption is usually that
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Varun Kumar et al. Effect of positioning of artificial teeth, contouring and body forms….

the denture is overextended so that the denture periphery may
be reduced. However, no matter how much the base is
reduced, it still pops up. It is not unusual to end up with a
denture base that is considerably smaller than the original size
but that still lacks stability and moves during the slightest
function. It is not the denture base that is the cause for denture
instability but, rather, the body of the denture, that is: the
tooth position and the flange form which was erected on top
of the denture base.
Stability of a lower denture is dependent on Muscle
function which affects: impression, occlusal plane, the arch
arrangement, jaw registrations, occlusal patterns, aesthetics,
the polished surface contour, food trough formation and
mastication and neuromuscular skills.
Muscles and their functional activity affect impression
procedures by power, anatomic attachment height and
creation of valve-seal borders. When treating patients with
above average muscular force, many dentists prefer to use the
selective pressure method of impression making. The closer
the frenum attachment is to the crest of the region, the less
basal seat region is available for the physical factors of
retention that include adhesion, cohesion, atmospheric
pressure, capillarity, and interfacial surface tension. Proper
border extension is an imperative of impression making,
particularly where the mandible is concerned1. The labial and
buccal vestibular muscles are primarily muscles of
dislodgment.
The musculature of the denture space is divided into two
groups: those muscles which primarily dislocate the denture
during activity and those muscles that fix the denture by
muscular pressure on its secondary supporting surfaces.
Martonet10 emphasized that the tongue, which rests upon the
mandibular ridge, will stabilize the lower denture. The tongue
is considerably more powerful than the lips and cheeks. The
tongue can exert a force of 16.4 psi12 while the lips and
cheeks can exert only 4.3 psi. 10 The lingual therefore is the
surface of choice when external contours are moulded.
Considerable care must be taken, because the lingual
influence can mitigate against stability.
Without muscular contraction and relaxation, movement
of the mandible would be impossible. The act of depressing
the mandible involves the suprahyoid and the platysma
muscles, infrahyoid muscle and lateral pterygoid muscles.
The muscles that elevate the mandible are the temporal,
masseter and internal pterygoid muscles. The external
pterygoid muscle is the guidance muscle of mandibular
movement. The condyles and teeth only modify movement
that is initiated by the neuromuscular system.8
A thorough understanding of the anatomy and
physiology of structures that impact sound complete denture
fabrication and function is important for successful treatment
of edentulous patients. Use of the neutral zone method to
identify and register the anatomy and physiology of oral
tissues that impact the prosthesis stability may result in
improved prosthodontic therapy for patients having resorbed
mandibular ridges.
Conclusion
This article presents a clinical technique which emphasised
on the appropriate arrangement of denture teeth and
considerations for the contouring and body forms of complete
denture polished surfaces. Neutral zone dentures showed
significantly higher patient satisfaction in cases of severe
resorption of mandibular ridge than conventionally fabricated
dentures.

Source of funding
None.

Conflict of interest
None.

References
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2.
3.
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6.
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The muscles of lingual fixation are the superior and
inferior lingual longitudinals, the lingual transverse, the 8.
lingual vertical, and the genioglossus muscles. The first four
are the intrinsic tongue muscles that control shape and form.
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How to cite this article: Kumar V, Dhami R, Kaur A, Aeran

V. Effect of positioning of artificial teeth, contouring and
body forms following rehabilitation of resorbed mandibular
ridges: Case reports. Int J Oral Health Dent 2019;5(3):157-
62.

International Journal of Oral Health Dentistry, July-September, 2019;5(3):157-162 162

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